Zero-Contrast Transcatheter Aortic Valve-in-Valve Implantation Using Intravascular Ultrasound to Evaluate Coronary Obstruction Risk

An 89-year-old woman with a history of advanced chronic kidney disease presented with symptomatic severe stenotic degeneration of a 19-mm Mitroflow bioprosthesis (Sorin Group USA, Arvada, CO, USA). Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) with zero contrast was planned due to an elevated risk for redo-surgical aortic valve replacement and contrast-induced nephropathy. Preoperative non-contrast computed tomography revealed a low-lying left coronary ostium with a short virtual valve-to-coronary distance (Figure A,B). Thus, up-front left main protection was performed with an undeployed coronary stent. A 23-mm CoreValve Evolut Pro (Medtronic, Minneapolis, MN, USA) was unsheathed successfully, followed by bioprosthetic valve fracture. There was no clinical or ECG evidence of coronary artery occlusion. After engagement of a 2nd guide catheter through the CoreValve (Figure C) and subsequent removal of jailed protective devices, intravascular ultrasound (IVUS) confirmed a large para-ostial space with no evidence of bioprosthetic leaflets hindering the coronary flow (Figure E). Thus, there was no indication for ostial chimney stenting. She had an excellent post-TAVR recovery.

Figure.

(A,B) Low-lying left coronary ostium with a short virtual valve-to-coronary distance. (C,D) Guidewire advancement through re-engaged 2nd guide catheter before removing jailed protective devices, followed by advancement of the guide catheter extension. (E) IVUS images of the large para-ostial space without any degenerated leaflets occluding the LM ostium. (F) Final fluoroscopy image. Ao, aorta; IVUS, intravascular ultrasound; LCC, left coronary cusp; LM, left main coronary artery; NCC, non-coronary cusp; RCC, right coronary cusp.

It is challenging to evaluate coronary obstruction without contrast agents. We believe that IVUS through the reengaged 2nd guiding catheter was the most crucial part of our approach because the true risk of coronary obstruction should be evaluated after removing protective devices. Moreover, stent implantation through a normally placed guide catheter has a smaller risk of stent deformation than traditional chimney stenting and facilitates future coronary access when needed.

Disclosures

A.L. has served on advisory boards for Medtronic, Boston Scientific, Philips, Edwards Lifesciences, and Abbott. Y.K. has served as a consultant to ACIST Medical Systems Inc. and Abbott Vascular Inc.